Provider Demographics
NPI:1326187253
Name:MULLETTE, LESLIE M (LICENSED OTR, ATP)
Entity type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:M
Last Name:MULLETTE
Suffix:
Gender:F
Credentials:LICENSED OTR, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 BONDURANT CT # B
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-1401
Mailing Address - Country:US
Mailing Address - Phone:406-549-2010
Mailing Address - Fax:406-243-4730
Practice Address - Street 1:MONTECH
Practice Address - Street 2:634 EDDY AVE
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59812-0001
Practice Address - Country:US
Practice Address - Phone:406-243-5486
Practice Address - Fax:406-243-4730
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT56225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT660950OtherBLUE CROSS BLUE SHIELD MT
MT347276Medicaid
MT347276Medicaid